EPO Health Insurance Plan Reviews and Buying Guide

Updated: September 27, 2022
epo plan

Do You have a Strong Reason to Choose an EPO Plan for Healthcare?

When looking for a new health insurance policy, you may be wondering if an EPO plan is right for you. Do you have a strong reason to choose an EPO over an HMO? With so many different options available, it can be tough to decide which plan is right for you. You may be wondering if an EPO is right for you. We’re here to help, so don’t worry. In this blog article, we’ll discuss what makes an EPO stand out from other health coverage and why it may be the right choice for you.


What is EPO insurance?

 EPO, or exclusive provider organization, is a type of health care management insurance.

The reason why EPO health insurance has this designation is that the EPO will only pay for medical expenses if they are paid for by healthcare organizations with which the EPO has a contract.

EPOs, like other health plans that require you to pay a monthly premium, will pay for out-of-area care in emergencies to stay within their managed care organizations.

EPO health plans feature cost-containment guidelines about how you receive your medical care, just like their cousin’s PPOs & HMOs.

When you receive medical attention, your EPO can’t afford to pay for it if you don’t abide by its guidelines.


epo plan review


How Does EPO Plan Work?

You are only covered for the healthcare you receive from in-area providers under an EPO insurance plan, with the exception of emergencies or when you have prior authorization from your insurance company.

With an EPO, references are typically not required, but you might require your EPO provider’s prior clearance before accessing various medical treatments.

Unless it’s an emergency, you will be responsible for paying the full value of the services you enjoy if you travel outside the network. If not, you must first get your insurance company’s approval before receiving treatment.

Who Should Get an EPO Plan for Healthcare?

If you don’t want the hassles of gaining referrals and prefer to manage your own care without the assistance of a primary care physician, an EPO health insurance plan may be a decent choice.

It’s also a smart decision if you want a plan with some flexibility but doesn’t want to pay the highest PPO cost.

Do not forget that an EPO plan does not offer coverage for services received from outside the network.

An EPO plan might not meet your family’s healthcare coverage needs if you like to be able to select any specialist or facility you want or if you already work with providers who are not in the EPO’s pool.

How to Get an EPO Plan?

You can only select an EPO Medicaid plan if your employer offers it or if you have group health insurance via your job. Get free healthcare quotes at NewHealthInsurance and this will help you to choose and purchase it.

You can purchase an EPO through the ACA’s new insurance exchange if your employer doesn’t carry coverage.

Only during Open Enrollment, which occurs from November to December and allows anybody to purchase an insurance policy, may you choose a new plan.

You might be eligible for Special Enrollment, which enables you to enroll in a new plan outside of the Open Enrollment period, if you switch employment or through a significant life-changing event, such as the birth of a baby.


Alternative to EPOs

Only four different kinds of health insurance plans exist HMO, EPO, PPO, and POS.

The one that is best for you will depend on your medical needs because they all have different benefits and drawbacks. Here are a few significant variations to be aware of as you select a plan.


Plan feature EPO PPO HMO POS
A general practitioner Usually required  Not required   Required  Required


coverage outside of networks emergency


Covered, however at a price  emergency    only Covered, however at a price
coverage for specialist visits No referral is necessary No referral is


 Only through referral only through referral
Pre-authorization is necessary Usually No NO Usually
Comparative premium price Middle Higher Lower Middle

How Much Does an EPO Plan Cost?

Intermediate rates are typically offered by EPO plans; however, actual costs will vary depending on your location and the particular plan you have.

In addition to premiums, it’s important to compare out-of-pocket peak values, copays (both in and outside of the zone), copays, taxes, and other fees.

 These are the highest amounts you will ever pay before your insurance starts paying 100% of your expenses.

A health insurance subsidy is an option if you require assistance with your monthly premium payments.


What is the Difference Between EPO and PPO?

When it comes to choosing an outside doctor in your area, a PPO plan gives you the most flexibility.

The cost of out-of-zone care is higher for PPO members since their insurance company only covers a lesser percentage of in-network healthcare.

An EPO plan, on the other hand, does not cover any portion of out-of-zone care Similar to an EPO plan, a PPO plan does not mandate that you engage with a primary care doctor or obtain a recommendation to visit a specialist.

However, PPO plans are typically more costly than EPO plans because of the higher levels of coverage and increased flexibility.

Differences between EPO and PPO

Feature EPO PPO
Price Cheap Expensive
Is care received outside of my network covered? No No
Referrals? No No

How Does EPO Plan Differ From Other Types of Health Insurance?

In an EPO, you are expected to solely use in-network suppliers, much like an HMO.

Except in cases of emergency or with your provider’s prior agreement, you will be responsible for the entire cost of the services you receive if you travel outside of the network.

A PPO, often known as a “preferred provider organization,” offers extra coverage for the network of plan providers. An EPO does not.

In a PPO, you still receive coverage from providers outside your network.

Just be aware that the costs for the services provided there are higher.

PPOs typically allow you to select a primary care physician (PCP) if you so wish. In order to receive specialist recommendations when you have an HMO, you must have a primary care physician who you see first.

Having an EPO frequently doesn’t necessitate the need for a PCP. If you go to in-network practitioners, you can frequently see specialists or undergo lab testing without having a referral, as EPO members typically do not have a primary care physician.

However, prior to receiving treatment, you might need to obtain prior authorization from your EPO provider for some services.

In contrast to PPOs, which typically allow you to receive treatment without prior approval, this is also true of HMO plans.

The type of insurance plan determines how you pay as well. A premium or a set amount is often required for the services you receive under an EPO, much like an HMO.

This is separate from a PPO, which usually has an annual premium and could also have separate deductibles for hospital facilities and prescription medicines.


epo health insurance plan


What network should you pick?

You actually have to decide the answer to this question for yourself because everyone has totally different needs from their medical insurance. But there are some tips you should bear in mind:

  • Make a list of the benefits and provider networks you must have a “desire to have” before you begin your search. Include a list of any physicians or healthcare centers you wish access to. While shopping, have that knowledge close at hand.
  • Before making any judgments, look out for nearby drugstores, clinics, and physicians in the networks you’re considering, especially if quick access to healthcare is essential.
  • Choosing an HMO / EPO could also provide cheaper monthly payments for you if your doctor is in-network or if you’re selective about where you obtain treatment and can easily survive in-network.
  • Consider PPOs or a more adaptable POS plan if you require the option to go outside a limited network while still receiving some privileges from your insurance.


Should I choose an EPO plan?

Pricing, selection, and flexibility are frequently important considerations when deciding among both EPOs or other health care plans.

A “middle ground” plan, an EPO allows you to consult a specialist immediately without a referral and has moderate rates. To get those services covered, though, your expert must be a part of the EPO plan’s group.

The cheapest and least flexible choice is HMO coverage. An HMO might be a decent choice for you if you have minimal health concerns, don’t feel like working with a PCP, and don’t mind staying in the plan’s territory.

PPOs, as was previously said, permit both in/out network treatment, but the expenses obtained outside the area/network are higher. The PPO charges are often the most expensive of the 4 various packages.


Pros and Cons of EPO Plan

Pros Cons
You are not required to go to a primary care doctor.  

If you don’t want to cover the full cost of your treatment, you must remain in the plan’s network.

You can visit specialists without a referral. EPO insurance has pros and cons, just like any other sort of insurance:
Due to their greater deductibles than HMOs, EPOs also typically offer lower premiums. Except in cases of emergency or prior authorization, care received outside the network of your insurance plan is not covered.
Compared to PPO plans, they frequently feature cheaper monthly rates but higher deductibles. EPO programs typically offer fewer options for doctors.


Bottom Line

EPOs have some characteristics with HMOs as well as some characteristics with PPOs.

As a result, one could think of an EPO as a hybrid of a PPO and HMO: You must stick to the plan’s network, similar to an HMO. To consult a specialist, however, you typically don’t need a recommendation from your primary care health professional, similar to a PPO. The simplicity of making an appointment with a specialist without first consulting a primary care physician attracts many consumers. However, since you are bound to a select set of experts in your group, this can sometimes present an issue.

You must actively engage in the preparation of costly treatments or procedures if you have an EPO, and you are the one who is ultimately responsible for obtaining any necessary prior authorizations. EPOs are generally a wise choice for many people due to their inexpensive premiums and minimal expense.


EPO Health Insurance FAQs:

What does EPO stand for in insurance?

A managed care plan that barring emergencies, services are only covered if you visit doctors, hospitals, or other healthcare providers in the plan’s network.


What is the difference between EPO and PPO?

With limited coverage or compensation for providers outside the area, a PPO offers more liberty. An EPO is more limited and offers less compensation or coverage for providers who are not in its network. The cost of an EPO is often less than a PPO for members with limited funds.


What is EPO vs HMO? Is EPO a type of insurance?

An Exclusive Provider Organization (EPO) is a less popular form of plan.

EPOs only pay for in-network healthcare; just like HMOs, their networks are typically more extensive. An EPO is a form of health policy that, in terms of price and flexibility, stands between a Preferred Provider Organization (PPO) and a Health Maintenance Organization (HMO)


What are the pros and cons of EPO? Who benefits from EPO?

Low monthly premiums: Although they are higher than those of health maintenance organizations (HMOs), EPO premiums are typically lower than those of preferred provider organizations (PPOs).

Large networks: Compared to HMOs, they typically provide a greater variety of medical professionals.


Is EPO the same as PPO or HMO?

EPO plans have a wider network than HMO plans but often lack PPO plans’ out-of-network advantages. EPO plans often charge more than HMOs but less than PPOs.

Why is EPO better than HMO?

While PPO plans often feature out-of-network advantages, EPO plans typically have a bigger network than HMO plans. Typically, EPO policies are much more expensive than HMOs but less expensive than PPOs.


Does EPO cause weight gain?

Recent research has demonstrated the pleiotropic effects of high-dose Epo treatment on fat and glucose metabolism, including changes in body weight, fat percentage, and glycogen breakdown.


What does evening primrose do to hormones?

One of the best sources of Gamma Linolenic Acid (GLA), an essential fatty acid that serves as the basis for female hormones, is evening primrose oil. As a result, it assists in maintaining hormonal balance. Preserving hormonal balance, good skin, and flexible joints play a crucial part in female metabolism.


Does EPO cause weight loss?

EPO users did not significantly lose more weight than placebo users when compared to participants with refractory obesity or those who were treated at the time of the initial appointment. It seems that EPO lacks any clinically meaningful anti-obesity properties.

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